EDITORIALS
Health Care Professional: Public Policy, Discrimination, and Patient Safety. Law, Medicine & Health Care 1991 (Spring, Summer)19:134-139.
6. Doe v Borough of Barrington, 729 F Supp 376 (D NJ 1990); Doe v Coughlan, 697 ]~ Supp 1234 [ND NY 1988)~ Woods v White, 689 F Supp 874 (WD Wis 1988}.
4. Doe v Coughlin, 687 F Supp 1234, 1237-1238 [ND NY 1988).
7. Occupational Exposure to Bloodborne Pathogens; Proposed Rule and Notice of Hearing. 54 Fed Reg 23042-139 (May 30, 1989).
5. Urbaniak v Newton, 226 Cal App 3d 1128 (1991}; Estate of Behringer v Medical Center, No. 188-2550 {NJ Super Ct Law Div, April 25, 1991).
8. HR 2707, amended September 11, 1991. 9. Possible transmission of human immunodeficiency
virus to a patient during an invasive dental procedure. MMWR 1990;39:489-493. 10. National Commission on Acquired Immune Deficiency Syndrome: America Living With AIDS: Transforming Anger, Fear and Indifference into Action. Washington, DC, US Government Printing Office, 199l. 11. Camus A: The Plague. New York, Vintage Books, 1972 ed, p 154.
EMS Data Collection: Filling in the Dots Among the 15 mandatory components of an effective emergency medical services system (EMSS) identified in the EMSS Act of 1973 was "standardized record keeping. ''l However, the collection of administrative, demographic, clinical, and epidemiological information on EMS has been hit and miss. Many investigators have commented on the difficulty of making intersystem comparisons due to the lack of standardization in EMS data collection. 2,3 See related article, p 1325. The specific system (microcomputer, optical m a r k reader, machinescannable first-care forms, and software) described in this issue of Annals by Joyce and Brown, and now p r o v i d e d c o m m e r c i a l l y b y Mr Brown's firm, was developed by them in southeastern Arizona where Dr Joyce was a member of the faculty of Emergency Medicine at the University of Arizona College of Medicine and Mr Brown was executive director of the Southeastern Arizona Emergency Medical Services Coordinating Council. Our experience with the system is therefore likely to be of some interest to readers of their article. The Office of Emergency Medical Services of the Arizona Department of Health Services sponsored some of the early work on this data collection system and encouraged its use by EMS p r o v i d e r s around the state. However, the system has never been adopted by the largest EMS providers in Arizona (the municipal fire departments of the cities of Phoenix and Tucson), and several smaller EMS organizations that initially tried the system have abandoned it. Joyce and 144/1381
Brown, in their discussion, touch on many of the issues that have figured in Arizona discussions of their optically scanned reporting system. The methodology of selecting data elements for inclusion in an optically scannable form represents no great scientific advance. Polling EMS services for data elements may merely document how widespread the misconception is that some data elements are useful. The authors' alternative criteria for data element select i o n ( e s t a b l i s h m e n t of a list of "essential" elements based on EMS literature review, personal experience, and local EMS practices) are no more or less scientifically valid than the suggestions of others experienced in the study and provision of prehospital emergency medical services.4, 5 We agree t h a t data b a s e d e s i g n should be v a l i d a t e d by o u t c o m e studies, an approach that has been significantly advanced by such investigators as Cobb, Copass, Cummins, Eisenberg, and Weaver. 3,6 In our experience, the optically scanned format is excellent for collection of n o m i n a l (eg, m o t o r c y c l e helmet use: yes or no) and ordinal (eg, Glasgow Coma Score) data. Continuous variables (eg, blood pressure) are less wieldy and require considerable space on the "fill in the dots" t y p e f o r m u s e d in an o p t i c a l l y scanned system, thus limiting the number of continuous variables that m a y be collected (unless, of course, one is willing to entertain a multipaged form). Other types of data are more problematic. For example, the current Arizona Department of Health Services optically scanned EMS First Care Form asks the EMS provider to document the intervals from collapse to Annals of Emergency Medicine
CPR, advanced life support care, and initial defibrillation for victims of nontraumatic cardiac arrest. The reliability of provider estimates, made in the heat of the resuscitation, for parameters such as these has been questioned - it has certainly never been established. 7 Moreover, the Arizona EMS provider has only four choices of dot to fill in: four minutes, four to eight minutes, eight to 15 minutes, or more than 15 minutes. Annals readers who have considered even the basic "Utstein" data set (intended for use in nonresearchoriented EMS systems) 8 will recognize the limited utility of the Arizona optically scanned EMS form for monitoring EMS system performance in this most-studied of prehospital medical problems. Thus, the Tucson Fire Department did not adopt this system at the time of its introduction because it had just embarked, in cooperation with the University of Arizona College of Medicine, on a citywide epidemiological study of sudden cardiac death. The detailed information required by the study was not available from the specific form and software to be used in this state. The Arizona experience with optically scanned EMS reporting also has raised wider p r e h o s p i t a l care questions. What is the purpose of collecting such data? Who should collect it? Statewide, centralized EMS data collection has a "morn and apple p i e " a t t r a c t i v e n e s s . However, data do not become information, a useful c o m m o d i t y , until t h e y are studied and interpreted by knowledgeable people. The Arizona state agency charged with overseeing EMS and that operates the aforementioned centralized reporting system in Ari20:12 December 1991
EDITORIALS
zona lacks personnel with the expertise and vision to transform EMS data to information and to put that information to any good use. Despite its s y s t e m s attributes, EMS remains primarily a local activity. Removing data collection and manipulation far from those actually caring for the patients, as has been attempted in Arizona, destroys its raison d'etre - improved care for the acutely ill and injured. The lack of enthusiasm on the part of Arizona EMS agencies for the Joyce-Brown system arises not from deficiencies in hardware and software, but from the sad experience that scarce state EMS resources have been diverted to this activity that does not assist EMS providers in better caring for patients. Arizona's experiment with centralization of EMS data collection has been an unhappy one. What have we learned from the experience? Statemandated data collection and reporting can lead to the imposition of "least c o m m o n d e n o m i n a t o r " data collection. In a state like Arizona, the resources, capabilities, and needs of the EMS community vary markedly from jurisdiction to jurisdiction. One must be careful, therefore, that any data collection system does not become an end in itself rather than, appropriately, a tool whereby the medical community obtains information to allow i m p r o v e d and less costly prehospital medical care. One must also be careful not to stifle innovation among local EMS agencies in the promulgation of a statewide system. Ironically, the Joyce-Brown approach to EMS data collection has within it the seeds of a solution to the problems it has created in Arizona. Optically scannable first care forms and associated computer hardware and software m a y be sufficiently inexpensive to allow the decentralization of EMS data collection. In other words, Arizona's Office of Emergency Medical Services drew precisely the wrong conclusions from the t e c h n i c a l possibilities of the Joyce-Brown approach. As Tom Peters points out in his book, Thriving on Chaos, the successful organiza20:12 December 1991
tion is the one that can "decentralize information, authority, and strategic planning. ''9 Instead, Arizona's Office of Emergency Medical Services attempted to centralize EMS data collection in its state capitol office. A more productive use of limited state EMS dollars would have been the provision of data systems such as those described by Joyce and Brown to the state's four regional EMS coordinating councils. Arizona's regional EMS coordinating councils are provided for in Arizona statute and consist of p h y s i c i a n s , nurses, local elected officials, and hea~lth care executives. Their purpose was the coordination of EMS policies and procedures across the state. Local medical p r o f e s s i o n a l s , w i t h i n t i m a t e knowledge and experience of their c o m m u n i t i e s ' EMS e n v i r o n m e n t , volunteered hundreds of hours of professional time to oversee and improve EMS. Unfortunately, the Arizona Department of Health Services management decided in 1987 to terminate funding of these agencies and to divert those resources to its own headquarters. The Office of Emergency Medical Services currently expends $120,900 to $182,800 annually just for salary and benefits of employees assigned to the EMS optically scanned data base program, lo According to Brown and Joyce, a complete system, including microcomputer, optical scanner, and software, can be had for approximately $21,000 to $38,000. Maintenance adds an additional $2,500 per year. Thus, taking high-end estimates, the amount of money spent currently by the Office of Emergency Medical Services for two years on centralized data collection could purchase Joyce-Brown systems for all four Arizona regional EMS councils with $79,800 to $203,600 to spare for use on other neglected priorities such as rural EMS needs, n Arizona's regional EMS councils were possessed of the necessary experience and expertise to transform mere EMS data into information as envisaged by Joyce and Brown: "... EMS planners could (using the optically scanned information system), determine response time, on-scene Annals of Emergency Medicine
time, and transport time for specific illness/injury classifications for any particular provider/agency ..." Note that such questions asked of the data base are necessarily informed by insight into local conditions. It is this realization that readily explains the failure of centralized EMS data collection in Arizona. Good medical control of EMS consists of ensuring prudent medical practice in the prehospital environment. A requirement for effective oversight is good information on prehospital care. The revolution represented by the increasing power and decreased cost of the microcomputer and the increasing computer sophistication of US society (including the EMS c o m m u n i t y ) m a k e possible EMS applications such as the innovative and excellent one described by Joyce and Brown. Perhaps solutions to the long-standing information gap in EMSS medical direction and management are finally at hand. Terence D Valenzuela, MD, FACER FACP Section of Emergency Medicine Arizona Health Sciences Center Tucson L Law of the 93rd Congress, Emergency Medical Services Act of 1978, Public Law 93-154, Washington, DC, November 14, 1973. 2. Eisenberg MS, Horwood BT, Cummins RO, et ah Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med 1990;19:179-186. 3. Eisenberg MS, Cummins RO, Damon S, et ah Recommendations for uniform definitions and data to report. Ann Emerg Med 1990;19:1249-1259. 4. Polsky SS: Medical record keeping, in Roush RR (ed): Principles of EMS Systems. Dallas, American College of Emergency Physicians, 1989. 5. Valenzuela TD, Criss EA: Data collection and ambulance call report design, in Kuehl AE led): EMS Medical Directors' Handbook. St Louis, CV Mosby, 1989. 6. Weaver WD, Cobb LA, Hallstrom AP, et ah Factors influencing survival after out-of-hospital cardiac arrest. J A m Coll Cardioi 1986;7:752 757. 7. Stewart RD, Burgman J, Cannon GM, et ah A computer-assisted quality assurance system for an emergency medical services system. Ann Emerg Med 1986; 14:25-29. 8. Cummins RO, Chamberlain DA, Abramson NS, et ah Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein style. Ann Emerg IVied 1991;20:861-874. 9. Peters T: Thriving on Chaos. New York, Harper and Row, 1987. 10. Office of Emergency Medical Services, Arizona Department of Health Services. I1. US Congress, Office of Technology Assessment, Rural Emergency Medical Services-Special Report, OTA-H-445. Washington, DC, US Govemment Printing Office, November, 1989.
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Health Care Professional: Public Policy, Discrimination, and Patient Safety. Law, Medicine & Health Care 1991 (Spring, Summer)19:134-139.
6. Doe v Borough of Barrington, 729 F Supp 376 (D NJ 1990); Doe v Coughlan, 697 ]~ Supp 1234 [ND NY 1988)~ Woods v White, 689 F Supp 874 (WD Wis 1988}.
4. Doe v Coughlin, 687 F Supp 1234, 1237-1238 [ND NY 1988).
7. Occupational Exposure to Bloodborne Pathogens; Proposed Rule and Notice of Hearing. 54 Fed Reg 23042-139 (May 30, 1989).
5. Urbaniak v Newton, 226 Cal App 3d 1128 (1991}; Estate of Behringer v Medical Center, No. 188-2550 {NJ Super Ct Law Div, April 25, 1991).
8. HR 2707, amended September 11, 1991. 9. Possible transmission of human immunodeficiency
virus to a patient during an invasive dental procedure. MMWR 1990;39:489-493. 10. National Commission on Acquired Immune Deficiency Syndrome: America Living With AIDS: Transforming Anger, Fear and Indifference into Action. Washington, DC, US Government Printing Office, 199l. 11. Camus A: The Plague. New York, Vintage Books, 1972 ed, p 154.
EMS Data Collection: Filling in the Dots Among the 15 mandatory components of an effective emergency medical services system (EMSS) identified in the EMSS Act of 1973 was "standardized record keeping. ''l However, the collection of administrative, demographic, clinical, and epidemiological information on EMS has been hit and miss. Many investigators have commented on the difficulty of making intersystem comparisons due to the lack of standardization in EMS data collection. 2,3 See related article, p 1325. The specific system (microcomputer, optical m a r k reader, machinescannable first-care forms, and software) described in this issue of Annals by Joyce and Brown, and now p r o v i d e d c o m m e r c i a l l y b y Mr Brown's firm, was developed by them in southeastern Arizona where Dr Joyce was a member of the faculty of Emergency Medicine at the University of Arizona College of Medicine and Mr Brown was executive director of the Southeastern Arizona Emergency Medical Services Coordinating Council. Our experience with the system is therefore likely to be of some interest to readers of their article. The Office of Emergency Medical Services of the Arizona Department of Health Services sponsored some of the early work on this data collection system and encouraged its use by EMS p r o v i d e r s around the state. However, the system has never been adopted by the largest EMS providers in Arizona (the municipal fire departments of the cities of Phoenix and Tucson), and several smaller EMS organizations that initially tried the system have abandoned it. Joyce and 144/1381
Brown, in their discussion, touch on many of the issues that have figured in Arizona discussions of their optically scanned reporting system. The methodology of selecting data elements for inclusion in an optically scannable form represents no great scientific advance. Polling EMS services for data elements may merely document how widespread the misconception is that some data elements are useful. The authors' alternative criteria for data element select i o n ( e s t a b l i s h m e n t of a list of "essential" elements based on EMS literature review, personal experience, and local EMS practices) are no more or less scientifically valid than the suggestions of others experienced in the study and provision of prehospital emergency medical services.4, 5 We agree t h a t data b a s e d e s i g n should be v a l i d a t e d by o u t c o m e studies, an approach that has been significantly advanced by such investigators as Cobb, Copass, Cummins, Eisenberg, and Weaver. 3,6 In our experience, the optically scanned format is excellent for collection of n o m i n a l (eg, m o t o r c y c l e helmet use: yes or no) and ordinal (eg, Glasgow Coma Score) data. Continuous variables (eg, blood pressure) are less wieldy and require considerable space on the "fill in the dots" t y p e f o r m u s e d in an o p t i c a l l y scanned system, thus limiting the number of continuous variables that m a y be collected (unless, of course, one is willing to entertain a multipaged form). Other types of data are more problematic. For example, the current Arizona Department of Health Services optically scanned EMS First Care Form asks the EMS provider to document the intervals from collapse to Annals of Emergency Medicine
CPR, advanced life support care, and initial defibrillation for victims of nontraumatic cardiac arrest. The reliability of provider estimates, made in the heat of the resuscitation, for parameters such as these has been questioned - it has certainly never been established. 7 Moreover, the Arizona EMS provider has only four choices of dot to fill in: four minutes, four to eight minutes, eight to 15 minutes, or more than 15 minutes. Annals readers who have considered even the basic "Utstein" data set (intended for use in nonresearchoriented EMS systems) 8 will recognize the limited utility of the Arizona optically scanned EMS form for monitoring EMS system performance in this most-studied of prehospital medical problems. Thus, the Tucson Fire Department did not adopt this system at the time of its introduction because it had just embarked, in cooperation with the University of Arizona College of Medicine, on a citywide epidemiological study of sudden cardiac death. The detailed information required by the study was not available from the specific form and software to be used in this state. The Arizona experience with optically scanned EMS reporting also has raised wider p r e h o s p i t a l care questions. What is the purpose of collecting such data? Who should collect it? Statewide, centralized EMS data collection has a "morn and apple p i e " a t t r a c t i v e n e s s . However, data do not become information, a useful c o m m o d i t y , until t h e y are studied and interpreted by knowledgeable people. The Arizona state agency charged with overseeing EMS and that operates the aforementioned centralized reporting system in Ari20:12 December 1991
EDITORIALS
zona lacks personnel with the expertise and vision to transform EMS data to information and to put that information to any good use. Despite its s y s t e m s attributes, EMS remains primarily a local activity. Removing data collection and manipulation far from those actually caring for the patients, as has been attempted in Arizona, destroys its raison d'etre - improved care for the acutely ill and injured. The lack of enthusiasm on the part of Arizona EMS agencies for the Joyce-Brown system arises not from deficiencies in hardware and software, but from the sad experience that scarce state EMS resources have been diverted to this activity that does not assist EMS providers in better caring for patients. Arizona's experiment with centralization of EMS data collection has been an unhappy one. What have we learned from the experience? Statemandated data collection and reporting can lead to the imposition of "least c o m m o n d e n o m i n a t o r " data collection. In a state like Arizona, the resources, capabilities, and needs of the EMS community vary markedly from jurisdiction to jurisdiction. One must be careful, therefore, that any data collection system does not become an end in itself rather than, appropriately, a tool whereby the medical community obtains information to allow i m p r o v e d and less costly prehospital medical care. One must also be careful not to stifle innovation among local EMS agencies in the promulgation of a statewide system. Ironically, the Joyce-Brown approach to EMS data collection has within it the seeds of a solution to the problems it has created in Arizona. Optically scannable first care forms and associated computer hardware and software m a y be sufficiently inexpensive to allow the decentralization of EMS data collection. In other words, Arizona's Office of Emergency Medical Services drew precisely the wrong conclusions from the t e c h n i c a l possibilities of the Joyce-Brown approach. As Tom Peters points out in his book, Thriving on Chaos, the successful organiza20:12 December 1991
tion is the one that can "decentralize information, authority, and strategic planning. ''9 Instead, Arizona's Office of Emergency Medical Services attempted to centralize EMS data collection in its state capitol office. A more productive use of limited state EMS dollars would have been the provision of data systems such as those described by Joyce and Brown to the state's four regional EMS coordinating councils. Arizona's regional EMS coordinating councils are provided for in Arizona statute and consist of p h y s i c i a n s , nurses, local elected officials, and hea~lth care executives. Their purpose was the coordination of EMS policies and procedures across the state. Local medical p r o f e s s i o n a l s , w i t h i n t i m a t e knowledge and experience of their c o m m u n i t i e s ' EMS e n v i r o n m e n t , volunteered hundreds of hours of professional time to oversee and improve EMS. Unfortunately, the Arizona Department of Health Services management decided in 1987 to terminate funding of these agencies and to divert those resources to its own headquarters. The Office of Emergency Medical Services currently expends $120,900 to $182,800 annually just for salary and benefits of employees assigned to the EMS optically scanned data base program, lo According to Brown and Joyce, a complete system, including microcomputer, optical scanner, and software, can be had for approximately $21,000 to $38,000. Maintenance adds an additional $2,500 per year. Thus, taking high-end estimates, the amount of money spent currently by the Office of Emergency Medical Services for two years on centralized data collection could purchase Joyce-Brown systems for all four Arizona regional EMS councils with $79,800 to $203,600 to spare for use on other neglected priorities such as rural EMS needs, n Arizona's regional EMS councils were possessed of the necessary experience and expertise to transform mere EMS data into information as envisaged by Joyce and Brown: "... EMS planners could (using the optically scanned information system), determine response time, on-scene Annals of Emergency Medicine
time, and transport time for specific illness/injury classifications for any particular provider/agency ..." Note that such questions asked of the data base are necessarily informed by insight into local conditions. It is this realization that readily explains the failure of centralized EMS data collection in Arizona. Good medical control of EMS consists of ensuring prudent medical practice in the prehospital environment. A requirement for effective oversight is good information on prehospital care. The revolution represented by the increasing power and decreased cost of the microcomputer and the increasing computer sophistication of US society (including the EMS c o m m u n i t y ) m a k e possible EMS applications such as the innovative and excellent one described by Joyce and Brown. Perhaps solutions to the long-standing information gap in EMSS medical direction and management are finally at hand. Terence D Valenzuela, MD, FACER FACP Section of Emergency Medicine Arizona Health Sciences Center Tucson L Law of the 93rd Congress, Emergency Medical Services Act of 1978, Public Law 93-154, Washington, DC, November 14, 1973. 2. Eisenberg MS, Horwood BT, Cummins RO, et ah Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med 1990;19:179-186. 3. Eisenberg MS, Cummins RO, Damon S, et ah Recommendations for uniform definitions and data to report. Ann Emerg Med 1990;19:1249-1259. 4. Polsky SS: Medical record keeping, in Roush RR (ed): Principles of EMS Systems. Dallas, American College of Emergency Physicians, 1989. 5. Valenzuela TD, Criss EA: Data collection and ambulance call report design, in Kuehl AE led): EMS Medical Directors' Handbook. St Louis, CV Mosby, 1989. 6. Weaver WD, Cobb LA, Hallstrom AP, et ah Factors influencing survival after out-of-hospital cardiac arrest. J A m Coll Cardioi 1986;7:752 757. 7. Stewart RD, Burgman J, Cannon GM, et ah A computer-assisted quality assurance system for an emergency medical services system. Ann Emerg Med 1986; 14:25-29. 8. Cummins RO, Chamberlain DA, Abramson NS, et ah Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein style. Ann Emerg IVied 1991;20:861-874. 9. Peters T: Thriving on Chaos. New York, Harper and Row, 1987. 10. Office of Emergency Medical Services, Arizona Department of Health Services. I1. US Congress, Office of Technology Assessment, Rural Emergency Medical Services-Special Report, OTA-H-445. Washington, DC, US Govemment Printing Office, November, 1989.
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